Breast Cancer Management Update (2016)

Consultant Breast Surgeon الثدي جراحة استشاريEducation & Training Director

Al Hammadi Hospital الحمادي مستشفىRiyadh, KSA ,السعود5ية العربية المملكة الرياض

2016

BREAST CANCER MANAGEMENT UPDATEDr. Mohamad Al-Gailani FRCS الكيالني. محمد د

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Outline: Breast Cancer Management Update

Facts about Breast CancerClinical Presentation Family History Treatment: SurgeryAdjuvant TreatmentSummary & Conclusion

Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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BREAST CANCER FACTS

• Breast cancer is the most common cancer in women.• It is the second leading cause of death by cancer in women

next to lung cancer.• A girl born today has a cumulative 1:8 risk of developing

breast cancer during the course of her life.• Every 3 minutes a woman is detected to have breast cancer.


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World Health Organisation (WHO)

• Breast Cancer is among the leading causes of morbidity and mortality worldwide.

• Approximately 14 million new cases and 8.2 million cancer related deaths per anum.

• The number of new cases is expected to rise by about 70% over the next 2 decades.

• Annual deaths from breast cancer > half a million


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Breast Cancerin

THE KINGDOM Of SAUDI ARABIA (KSA)

• Incidence about 20 per 100,000 women• Tops the list of the most common cancers in women by a rate of about 28%• The predicted rate of breast cancer incidence will be more than quadruple in

the Middle East region during the next twenty years.• Presents in a Younger age group, average around 48 years of age, a decade

younger than in the west.• Around 73% of patients consult their doctor at an Advanced Stage. • Mammographic Breast Screening uptake is poor despite adequate facilities.


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October 2016

For Women from the age of 40 and above…Have you ever had a screening Mammography?

Yes16%

No, I don’t think it is essential34%

I don’t know where the screening centres are 50%

2,846 votesFinal Results

October 2016*


*MOH Twitter account questionnaire, October 2016

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Fungating Breast Cancer

Lymphoedema

New Contralateral

Cancer “Peau d ’Orange”

The Ugly Reality of Incurable Breast Cancer


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BREAST CANCER RISK FACTORS(* Modern Life Influences)

• Age (Y): 80 1:8, 50 1:50, 40 1:200, 30 1:2,500

• Family History: 10% BRCA1, BRCA2• Total Number of Menstrual Periods: Early Menarche < 12 Late Menopause >55• Late first childbirth* >30

• Not had children*• Not Breast Fed*• HRT*: > 10 years 66%• Obesity*: 30%• Alcohol*: 12%• Other factors: Smoking, OCP?,

Deodorants?, Diet?,…Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

BREAST CANCER

CLINICAL PRESENTATION


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WARNING SIGNS OF BREAST CANCER!

1. Discrete Lump in a patients >30 2. Ulceration, Skin Nodule, Skin Distortion (Dimpling)3. Nipple Eczema (Paget’s Disease) 4. Recent Nipple Retraction or Distortion (< 3 months)5. Unilateral Bloody Nipple Discharge


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BREAST CANCER CLINICAL PRESENTATIONS

BREAST LUMP NIPPLE INVERSION SKIN DIMPLING SKIN PUCKERING

BLOODY NIPPLE DISCHARGE

NIPPLE ECZEMA AXILLARY LUMP INFLAMMATORY CANCER


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BREAST CANCER SYMPTOMS WITH A SIGNIFICANT POSITIVE PREDICTIVE VALUE (> 3%)

Complaint Positive Predictive Value (PPV) %

Breast Lumpiness 2.6

Breast Pain 1.6

Breast Mass/ Discrete Lump 10


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FAMILY HISTORY

Breast CancerBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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Breast Cancer Family History

• 90% of Breast Cancer is Incidental.• 10% could be Familial.• Significant Family History = 3 or more Relatives, One First Degree, Young age, +/-Ovarian Cancer

• Average Risk: One 2nd or 3rd Degree Relative• Moderate Risk: In-between


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High (Significant) Risk Surveillance(Predicted Lifetime Risk Assessment

>30%)• Counselling & encourage Breast Self Exam• Annual MRI from age 30-49• Annual mammography from age 40• Genetic Testing if (>30% BRACA Carrier Probability)Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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BRACA Gene Carriers

• Breast cancer risk up to 80%• Ovarian cancer risk up to 50%• Available options:1. Surveillance for life2. Chemoprevention: Tamoxifen & Raloxefine3. Risk Reducing Mastectomy with Immediate

Reconstruction4. Prophylactic Laparoscopic OophorectomyBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS

Riyadh, KSA

BREAST CANCER TREATMENT

SurgeryBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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The Multi Disciplinary Team (MDT) Meeting

• A regular meeting (usually weekly) of a group of specialists of different modalities treating a certain condition and discussing best management plans for the patient.

• Ensures (Face to Face) effective discussion of every case from all aspects of management by all specialities involved.


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Composition of the Breast Multi Disciplinary Team (MDT)

• Surgeon• Oncologist• Radiologist• Pathologist• Breast Care Nurse• Geneticist? • Plastic Surgeon?


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Breast Conserving Surgery (Screen Detected Breast Cancer)

Marker (Wire)-Guided Wide Local Excision


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Breast Conserving Surgery

• Small tumour relative to breast size• No difference in long term survival or

local recurrence rate compared to mastectomy

• Highest achievable cure rate (up to 95%)

• Requires postoperative RadiotherapyBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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MASTECTOMY

• Indications:Unfavourable (Tumour:

Breast Size)Multicentric Breast

CancerPatient Preference

• Types:• Simple Mastectomy• Skin Sparing with

Immediate Reconstruction• Skin & Nipple Sparing with

Immediate ReconstructionBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

Breast Reconstructive Surgery


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Latissimus Dorsi Myo Cutaneous Flap

Skin Sparing Mastectomy with Implant & ADM

Acellular Dermal Matrix (ADM)

Breast ImplantsBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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Case 1Right Skin Sparing Mastectomy & Immediate Recon

Latissimus Dorsi (LD) Flap + Implant

Right Nipple Reconstruction Left Symmetrisation

Reduction

Op 1

Op 2

LD Muscle Harvest Wise Pattern Skin Sparing Mx.


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Case 2Left Skin Sparing Mastectomy + ADM Implant Immediate Reconstruction


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Case 3Left Skin & Nipple Sparing Mastectomy + Immediate Reconstruction + ADM & Implant


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Case 4Right Delayed LD Reconstruction + ImplantLeft Symmetrisation Reduction

PreOp

PostOp


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Sentinel Node Biopsy (SNB)

THE FIRST LYMPH NODE THAT DRAINS THE BREAST


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SENTINEL NODE BIOPSY CONCEPT

Technitium99& Blue Dye


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SNB

Subareolar injection site

Ant. Oblique View Lateral View

SCINTIGRAPHY


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“Europrobe” Gamma FinderBreast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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Removing the “Hot & Blue” Sentinel Node Measuring

Radioactivity Ex Vivo


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Adjuvant Therapy


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Long-term Risk of Breast Cancer Recurrence Remains High

0

0.1

0.2

0.3

0 1 2 3 4 5 6 7 8 9 10 11 12

Rec

urre

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haza

rd ra

te

Years

ER– (n=1305)ER+ (n=2257)

Plateau 1% per annumHighest first 5

years


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Adjuvant ChemotherapyTo Give or Not to Give?

• Adjuvant Chemotherapy or Hormonal therapy reduces the risk of distant metastases by approximately 30%.

• However 70-80% of patients receiving this treatment would have possibly survived without it!


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Adjuvant Chemotherapy

NO Adjuvant ChemotherapyKi67, Oncotype

DX

NPI=Size (cm)x0.2+Grade+LN


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Radiotherapy (RT)

• Following Breast Conservation Surgery:• RT 3 week course, 5 days a week• Following Mastectomy:• RT if large tumour (>4cm) or heavy axillary lymph node involvement (>4 lymph nodes)


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Hormone Treatment• 80% of breast cancers are hormone receptor positive• They will benefit from 5 years of hormone treatment• They have the extra benefit of protecting the contralateral breast• Available hormone treatments include:TamoxifenAnastrozoleLetrozoleExemestane


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Guidelines for Treatment of Breast CancerAdjuvant Hormone Treatment

Pre-Menopausal:

• Tamoxifen for five years.

Post-Menopausal: • Good risk (NPI < 3.4): Tamoxifen for 5 years

• Intermediate risk patients (NPI 3.4-5.4):

Tamoxifen for 2-3 years followed by an AI to complete 5 years treatment

• High risk patients (NPI > 5.4 or HER2+):

An AI from the outset for 5 years

*All patients with a recent history of thromboembolic disease or on long-term anticoagulation should receive an AI in preference to tamoxifen.


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Guidelines for Treatment of Breast CancerExtended Adjuvant Hormone Treatment

(beyond 5 years)

• An AI (usually Letrozole) extended adjuvant treatment for 2 years

• In patients considered at continuing significant risk for relapse

(e.g. Node positive)

• Completed 5 year course of Tamoxifen


HOW TO IMPROVE BREAST CANCER SURVIVAL?

Breast screening (Currently 16% uptake). Public Awareness & Breast Self Examination.Lifestyle changes: Obesity, HRT, Smoking,

Breast Feeding.High Risk Family History women: Chemoprevention with Tamoxifen &

Raloxifene.Risk Reducing Mastectomy + Immediate

Reconstruction.

Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA 42

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Summary

• Breast cancer is common and increasing in incidence in KSA.

• Women are more likely to present at an advanced stage.

• Breast screening is available, but uptake remains poor.

• Public health awareness is crucial and should be intensified.


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Conclusion

• Every woman should be Breast Aware and come forward for regular Screening Mammography from the age of 40 every 2 years.

• Public Health awareness efforts should be intensified and directed towards women and their families.Breast Cancer Management Update 2016 Dr. Mohamad Al-Gailani FRCS Riyadh, KSA

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Dr. Mohamad Al-Gailani .الكيالني محمد دConsultant Breast Surgeon الثدي جراحة استشاري

Fellow Royal College of Surgeons England الجراحين كلية زميلانكلترا, الملكية

Member British Association Breast Surgery (ABS)Member British Association Surgical Oncology (BASO)

Al Hammadi Hospital الحمادي مستشفى

www.alhammadihospital.com Riyadh, KSA

Health & Medicine

Breast Cancer Management Update (2016)